GW1-2022-07828_Well Construction - GW1_20220822

WEL,L CONSTRUCTION RECOIZI) —
This form can be used for single or multiple wells For Luenigl Use ONLY:
1,Well Contractor luformation:
Mitchell Dean Gook 14 wATFR roive;s
.... FROM 10 DF SCR Kn N
Well Contractor Name , ft. ��/ ft.
2043 A Q` e _
fr. fr.
NC Well Contractor Cenification Nwnbcr l_S OIJT.NR tSTN(' for.;mih ebsetlClle <'-� ) IINF}fl(f: "7icably
FROM TO DIAMFTF R 7TIICIQVESS MATERIAL ti._.._..
Dennis Holland Well Drilling, Inc. ft ft ;n -
Pvc
Company Name 16 iNN1 RlCASIN(: R"cU13ING' eol.0 me7;cluicd rod
FROM 1'0 DIAMETER 'THICKNESS MATERIAL
2.WeII ConstructioD Permit#: C7 ip 0�.,�„.�. -•� _ ft. r�, in. -
List u!1 applicable well permits(i.e.County,,Stare, Variance,Injection,etc.)- .� -� __.
ft. T ft in
3.Well tlse(check well use.): _ r
Water$llpply Well: " " FROM T(r DIAMETER SLOT SIZE THICKNESS MATtRIAI.
(_lAgrlcultural I::1MunicipaVPublic ft. ft. in.
OGeothermal(Henting/Cooling Supply) sidential Water Supply(single) ft. R. in.! -
01ndustrial/Commercial 17.11tesidential Water Supply(shured) IS (sRnU 1
Cllrfl fill(]]]
FROM TO _ MATERIAL EMPIACFMFNTMFTHODi&AMOlJNT
--
ft.
Nou-Water Supply Well:g URecovery hs�sft
Z)� ft, A 5-
y l�i�r� _ a�—,�t�e.
13Monitorin $ ft. ft.
Injection Well: - '"T'-'_ ft. � -ft,
DAquifer Recharge nGroundwaterRemediation 19..$.'tIp/C1tAVF)s'+YpC1C tfe licgl}le ;; <
ClAquifer Storage and Recovery C1Salinity Barrier FROM TO- MATERIAL EM PLACF:AIFNT MET110D� -
fr.^ _ R. _
OAquifer'rest (38tonnwater Drainage - a-
ft. ft.
C-IF,xperimental'l'eclulology LJSubsidence Control
C1GeothermalClosed Loop) _ 2U DRI1IsIN(y.l U affacFifmddlhoaahstiecfa tf necevseFyL ` ..;,, ;
( p) (,]Tracer FROM 7O) DMCRirTION color hard_. ne^soll/mck typtyfraioe_u,ctc�-
0(icothermal Qieating/Coolr�Return) UOther(explain under#21 Remarks) ft. fr.
/ rt. rt. --
4.Date Well(s)Complcted:Q)g% ft. - -2 fL
So.Well Location: l ft. --- -ft.
/i4. fr. _...___ft._ _ � to-$__ '
Facility/Owner Name Facility ID#(if applicable) - _-._..._.._..
ft, pill; ? 2Q22
Physical Address,City,and Zip -- . ^
zer , ,..;
County Parcel Identification No.(PIN) -
5b.Latitude find Longitude In degrees/minutes/seconds or decimal degrees: 22 (eltificntioo:��
(if well field,one lat/long is sufficient)
���.� Signanue ufCettified Well Contractor Date
6.Is(are)the well(s):`k�crmanent ,or 171'emporary By signing this fonu, I hereby certify that the well(s)was(were)constructed in accurdonce
with 15A NCAC 02C.0100 or 13A NCAC 02C.07.00 Well Construction Standards and that a
7.Is this 9 repair to aft existing well, ElYes or copy of this record has been provided to the well owner.
If this is a repair,full out known welt construction information and explain the noaue of the
repair under#21 remarks section or cal the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the.same construction,you can
submit one form. SUBMITTAL 1NSTUCTIONS
9.'rotai well depth below land surface:,' (ft,) 24a. For All Wells: Submit this limn within 30 clays of completion of well
hor multiple wells list all depths if different(example-3@200'and 2@/00') construction to the following:
10.Static water level below top of casing: _a���1 ' _ (ft.) Division of Water Resouices,Information Processing Unit,
If,vaterlevel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
H
11.Borehole diameter: (iu.) 24b. Forinjecli( Vel ONLY: Ln addition to sending the Focal to the address in
Rota 24a above, also subunit a copy of this fonn within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC.,27699-1636
13a.Yield m Method of test: Air lift 24c• For Water Su tj Ili@!n'ectitWells:
Also submit one copy of this focal I'within 30 days of completion of
13b.Disinfection type: M & M___ Amount:. ?� oz. well construction to the county health department of the county where
— _ constructed.
Fonn GW-I North Carofina Departuuent of Gnviroumeut and Natural Resources -Division of Water Resoluces Revised August 2013

Qiote��
d�•m Macon County NEW WELL CONSTRUCTION
Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
d � a
Joe Fowler • 080422=P_ _ • Existing_._....
................................................. _. ---...........
Sinn le-Famik.Well Only(set backs),.__Residential ' 7517066033 1.24
• • Lot 14 Silver Ridge at 160 Archie Pt.
' • 441N to L on Coon Creek Rd. to L on Archie Pt. to 160 on left at hard switchback.
_ ....--'-r----...._.._......._ ....__......_.....---'_._._.... -......._. _.._.._._............
_-
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable. °
Diagram (Not to Scale)
eti
P
Lot 14
Lot 15
House
"9q,' Note that new well may be located on lot 15
According to the aerial map.
s '
0�7 tv3,
_ a —_- --- Proposed well ---__.-._ —_--
Log 080422-P
L
- -
L
55
Gate N
r`
This permit is valid for a period of five years except that it may be revoked at any time if it is determined that there has been a material change in any factor
circumstance upon which the permit is issued. Well location, installation,and protection must meet state regulations.The well shall be inspected and approved by Macon County
Public Health before it is put into use. The location of the well indicated by MCPH is to provide prole::bon from possible sources of contamination. Flow voiume(well yield)is NOT
guaranteed at any site by MCPH.
A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRANTED OR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?[phone]
Issue Date: 8/5/2022 Charles Womack, REHS 1300 CIIML_�
joryA4LL.Authorized State Agent